When you have a hammer, everything looks like a nail. But achieving EHR interoperability, the Academy reminded policymakers in three letters sent June 3, will require a more diverse set of tools.
"The AAFP applauds the administration's continued push toward a nationwide interoperable health care system," the Academy said in a letter to HHS Secretary Alex Azar(35 page PDF) regarding a proposed rule on the 21st Century Cures Act.(www.govinfo.gov) "Family physicians routinely struggle with acquiring the right health information to make the best decisions with their patients. The lack of interoperability is a fundamental issue leading to increased cost, burden and frustration, as well as lowering quality and health."
All three letters were sent in response to proposed rules published March 4 in the Federal Register. In addition to the letter on the 21st Century Cures Act, the correspondence included
- a letter to Azar(3 page PDF) addressing a proposed rule on interoperability and patient access,(www.govinfo.gov) and
- a letter(2 page PDF) to National Coordinator for Health IT Donald Rucker, M.D., addressing the Trusted Exchange Framework and Common Agreement.(www.govinfo.gov)
"The AAFP urges HHS to keep current administrative burdens on practices top of mind in regard to the choice of enforcement regime to deter information blocking," the Academy said in letter on the 21st Century Cures Act. "These burdens hobble practices' ability to comply with current paperwork requirements, and compliance with information blocking protocols cannot add to this burden."
- The AAFP sent three letters to shape proposed rules meant to foster the exchange of information in EHRs.
- The current lack of interoperability increases administrative burden and cost, and decreases quality, the Academy wrote.
- The AAFP voiced strong support for HHS' push to drive adoption of open, standards-based application programming interfaces, while noting the need to limit new administrative burdens.
The letters, signed by Board Chair Michael Munger, M.D., of Overland Park, Kan., praised the administration's regulatory aims while offering detailed feedback about how the proposed rules could ultimately miss the mark.
One example: the administration's proposal to apply condition of participation requirements to the electronic exchange of information with a patient's primary care physician or medical home about admission, discharge and transfer.
Making such exchange the norm for hospitals is an advance the Academy welcomes -- but mandating conditions of participation, the Academy told HHS in the letter regarding the interoperability and patient access proposed rule, "represents a powerful policy hammer that should be used extremely judiciously."
That kind of blunt force, the letter added, could harm access to care at small or rural hospitals that are unable to comply. "Given the current state of infrastructure and standardization in this area, the implementation by many of the hospitals will not have good usability for physicians."
Likewise, the Academy voiced strong support for HHS' push to drive adoption of open, standards-based application programming interfaces, while noting the need for refinement to limit new administrative burdens.
"We agree with adding the requirement for health plans to deploy API access to patients," the AAFP said. "We also believe these APIs should be made available for physicians and other health care providers such that they can also have ready access to these needed data."
The Academy noted that API access would support cost-effective continuity of care and care coordination.
"One area of concern, though, is in the requirement to make these data available in one business day and the recommendation for health plans to amend contracts with physicians and other health care providers to require near real-time data submission. … We oppose this mandate and ask that CMS remove the requirement that physicians and other health care providers submit claims and encounter data in near real time."
The Academy also objected to any API rule that would give payers unfettered access to physician EHRs.
"We strongly oppose such access, as the physician and patient may have data within the EHR that the patient does not want to share with the payer," the AAFP said. "Such access may also lead to selective, discriminatory reimbursement models and intrude on physician medical decision-making."
The Academy addressed several other topics in its feedback.
"The 21st Century Cures Act(www.fda.gov) is a welcome new component of our national health policy and makes information blocking illegal," the Academy wrote. "The challenge HHS must overcome is to thread the needle between penalizing true information blockers while not adding complexity, uncertainty and burden upon practices who are not blocking information."
To achieve this, the AAFP said, HHS should "work aggressively to simplify the rules with small- and medium-size physician practices in mind."
The Academy said HHS should simplify its definition of electronic health information by distinguishing between data that are part of the U.S. Core Data for Interoperability(www.healthit.gov) and data that are "reasonably requested and reasonably available for exchange."
"Without the stipulation whether EHI is 'requested,' we are concerned that compliance departments within health care organizations will default to send all data for every exchange," the Academy wrote. "Unintended consequences such as this interpretation have occurred with the transitions of care exchange requirements of meaningful use."
And noting that the proposed rule qualified any single instance of information blocking as a violation, the Academy called for a more lenient final rule, "until the standards for data segmentation for privacy have matured and have been properly implemented in certified EHR technology."
National Provider and Plan Enumeration System
The Academy expressed support for including digital contact information in the National Provider and Plan Enumeration System but warned of ongoing concerns with quality and outdated information.
"CMS should work with state and private entities to establish APIs that would allow for a single point for a physician to update their information and allow these data to extend to all appropriate state and federal entities," the AAFP wrote.
Electronic health information export
"Family physicians experience high costs to extract data on patient populations out of EHRs or have been told to manually extract each patient in the EHR user interface," the Academy advised. "The AAFP strongly supports the inclusion of database export as a criterion for 2015 Edition CEHRT."
"We are pleased to see the proposed rule limits fees by vendors to those that are 'necessary and reasonable,' yet the AAFP is concerned that EHR vendors, app developers, payers and health information exchanges can charge necessary and reasonable fees while physicians and practices are precluded from charging patients such necessary and reasonable fees," the Academy said.
"The AAFP strongly recommends HHS either allow all entities to charge necessary and reasonable expenses or bar all entities from charging for interoperability costs. Of course, not allowing necessary and reasonable fees would stifle innovation and development toward interoperability."
Finally, the AAFP expressed concern with the timelines laid out in the proposed rule on the 21st Century Cares Act.
"Given the impact and complexity of this proposed rule, we request that HHS release a supplemental notice of proposed rulemaking with comment period rather than a final rule," the Academy wrote.
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